Stefan Jaeckle

Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients.

OBJECTIVE:Mediastinal lymphadenopathy (ML) is a cause for concern, especially in patients with previous malignancy. The investigation of choice is thoracic CT with a variable sensitivity and specificity requiring tissue diagnosis. We used endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of ML in patients with and without previous malignancy. The cause, distribution of lesions, and incidence of second cancers were investigated.METHODS:Linear echoendoscopes and 22-gauge needles for cytology were used for EUS-FNA. A cytological diagnosis of malignancy was accepted, and histology or consistent follow-up of at least 9 months confirmed benign results.RESULTS:One hundred fifty-three patients underwent EUS-FNA between November 1997 and November 1999 (mean age, 60 yr; range, 13–82 yr; 105 men). Cytology was adequate in 150 patients. Final diagnosis was malignancy in 84 and benign in 66 patients (sensitivity, specificity, and diagnostic accuracy: 92%, 100%, 95%, respectively). In 101 patients without previous cancer cytology identified 48 malignant (lung, 41; extrathoracic, 7) and 51 benign lesions (inflammation, 35; various, 9; sarcoidosis, 7) (sensitivity, specificity, accuracy: 88%, 100%, 94%). Fifty-two patients had prior malignancy, mostly in extrathoracic sites. Cytology revealed recurrences in 21 patients, second cancer in 9 and benign lesions in 21 patients (inflammatory, 11; sarcoidosis, 8; tuberculosis, 1; abscess, 1) (sensitivity, specificity, accuracy: 97%, 100%, 98%).CONCLUSIONS:In patients without previous cancer malignant ML originates from the lung >80%. In those with previous malignancy recurrence of extrathoracic sites is the major cause. Benign lesions and treatable second cancers occur in a significant frequency, emphasizing the need for tissue diagnosis. EUS-FNA is a safe and minimally invasive alternative for cytodiagnosis in the mediastinum.

Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis

OBJECTIVE: Therapeutic endoscopy may be effective in selected patients with chronic calcific pancreatitis (CCP). We prospectively evaluated the early outcome of extracorporeal shockwave lithotripsy (ESWL) in combination with interventional endoscopy, using broad inclusion criteria. METHODS: A total of 48 consecutive patients (35 male, 13 female) were recruited for ESWL and endoscopic therapy of symptomatic CCP. Symptoms, quality of life, pancreatic morphology and function were assessed before and after ESWL. RESULTS: Multiple stones (n = 43), strictures (n = 34), and pancreas divisum (n = 11) were found. A median of 13 ESWL sessions (range 2–74) with a median of 22,100 shockwaves (1,700–150,900) were required. Endoscopic pancreatic sphincterotomy (n = 48), stricture dilation (n = 12), and/or stenting (n = 27) were performed. After therapy, drainage of the pancreatic duct system was achieved in 36, complete stone clearance in 21 patients. Follow-up (n = 38) at 7 months (range 5–9) showed a significant decrease in pancreatic duct diameter (p < 0.001) and pain score (p < 0.0001) whereas complete pain relief was observed in 45% of cases. Several quality of life scores improved significantly. Weight gain occurred in 68% of patients. Normalization of fasting blood glucose and HbA1c levels were observed in four patients, without modifying their treatment. Improvement in pain score correlated with weight gain and decrease in pancreatic duct diameter. Nonalcoholic etiology was associated with a better chance for improvement in pain score and decrease in pancreatic duct diameter. The presence of strictures did not deteriorate the clinical outcome. CONCLUSIONS: Besides pain relief, ESWL in combination with interventional endoscopy resulted in pancreatic ductal decompression, weight gain, and improvement in quality of life in a considerable number of patients with advanced CCP.

Endosonography-guided, fine-needle aspiration cytology extending the indication for organ-preserving pancreatic surgery

Abstract OBJECTIVE: Organ preserving pancreatic resections are considered whenever malignant disease is ruled out. In tumors of low malignant potential such as cystadenomas and neuroendocrine tumors, the diagnosis is rarely established preoperatively. We studied the feasibility of cytodiagnosis using endosonography-guided fine-needle aspiration in determining the operative approach. METHODS: A total of 78 patients (16 female, 62 male; mean age 61.4 yr, range 31–82 yr) with focal pancreatic lesions underwent EUS-FNA. Final diagnosis was confirmed by histology, cytology, or clinical follow up (>9 months). Patients with tumors of low malignant potential were managed by customized pancreatic resections. RESULTS: Final diagnosis was malignant tumors in 36 patients, tumors of low malignant potential in nine (six, neuroendocrine, two, borderline mucinous cystadenomas, one, borderline adenocarcinoma), and benign in 31 (two inadequate smears). No complications occurred. With six false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 92%, 84%, 100%, 100%, and 86%, respectively. Five patients with low malignant tumors underwent duodenum-preserving pancreatic head resection, three mid segment resection, and one pylorus-preserving pancreatoduodenectomy. CONCLUSIONS: EUS-FNA is useful in the preoperative cytodiagnosis of pancreatic tumors of low malignant potential. It extends the indication for organ-preserving pancreatic resections and avoids the unnecessary sacrifice of adjacent organs.

Synchronous adenocarcinoma in the transposed colonic conduit after esophagectomy for squamous cell cancer: endoscopic palliative resection while awaiting surgery

Reconstruction of the GI tract after esophagectomy is a challenging surgical procedure. Most surgeons prefer to mobilize the stomach as a reliable organ for substitution. The colon is only used in about 20% and is chosen when the use of the stomach appears to be inadequate or it is technically difficult to mobilize.1 Early complications of replacement using the colon are ischemic necrosis, anastomotic leak with fistula, and stricture formation.2 Primary cancer of the colon is one of the most frequent malignant tumors in the Western world and the second most common cause of cancer deaths.3 In a review of available reports, we could find only five cases of primary colonic cancer in the interposed colon 20 months to 20 years after reconstruction.4-8 We report here a case of colonic cancer in the interposed right colonic segment which was detected 7 months after esophagectomy for squamous cell carcinoma of the esophagus.

4677 Endoscopic treatment of 64 patients with mirizzi`s syndrome.

Background: Mirizzi`s syndrome is defined as extrinsic compression of the common bile duct by an impacted stone in the cystic duct or the neck of the gallbladder. Surgery is often difficult due to extensive inflammation. Aim: Evaluation of endoscopic treatment of Mirizzi`s syndrome in the largest series reported yet. Methods: Retrospective evaluation of patients (pts) presenting with Mirizzi`s syndrome between 1990 and 1999.For initial stabilisation or safe transport to our center, temporary stents or nasobiliary drainage (NBD) were placed. If the stone could be caught into the Dormia basket, mechanical lithotripsy (ML) was performed. Otherwise electrohydraulic lithotripsy (EHL) using the Mother-Baby scope system (Olympus Co.,Tokyo, Japan) and the Walz lithotriptor (Fa. Walz, Rohrdorf, Germany) was performed to fragment stones under cholangioscopic view. Results: 48 f and 16 m pts with a median age of 71years (14-94y) were included. Median duration of biliary symptoms was 22 days (1 d-5 y). Patients presented with pain in 64%, obvious jaundice in 66% and painless jaundice in 22%. 19% were in poor general condition. 9 pts had undergone cholecystectomy median 3 y before (0.1-23 y). An initial endoscopic stent or NBD was placed in 30 pts (47%). Median size of stones was 2cm (0.7- 5cm). In 8 pts ML was performed. 52 pts required EHL. Complete duct clearance was achieved in 59 pts (92%). A single lithotripsy session was sufficient in 54 pts. 4 pts were treated by stenting or nasobiliary drainage only. A complicated course was observed in 4 pts: 2 pts with cystic duct leak at the site of pressure necrosis recovered conservatively.A 71y male not sent for the 2nd session of lithotripsy was treated with long term stenting in another hospital and developed small bowel perforation by the dislodged stent. A 90 y female with septicemia treated by NBD, had myocardial infarction after 2 d and died after 3 d. Subsequently, 12 pts underwent cholecystectomy. 4 of them were symptomatic after endoscopy due to cholelithiasis (3 patients had cholecystitis after 7 d, 7 d and 56 d, respectively; 1 pt had biliary colics after 2 y). 39 pts did not undergo surgery and have remained asymptomatic over a median follow up of 28 months (2-82). None of the pts developed biliary malignancy over a median follow up of 24 (0-85) months. Conclusion: Mirizzi`s syndrome, being considered a clear indication for surgical management, can be safely and effectively treated by endoscopy even in elderly and severely ill pts. Coincidence of gallbladder malignancy with Mirizzi`s syndrome was not observed.

4558 Preliminary results of eus guided fine-needle aspiration cytodiagnosis of hilar cholangiocarcinoma.

Background: In spite of improvement of diagnostic modalities tissue diagnosis of obstructions at the liver hilum remains a challenge. Extensive hepatic resections with intention to cure or modern palliative concepts require exact diagnosis, which is rarely achieved preoperatively. Attempts were made by brushings and biopsies during ERCP with variable sensitivity. This is the first report of endosonograpghy guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of hilar cholangiocarcinoma. Methods: 10 patients (7 male, 3 female, age: 47-78, mean age: 62.5) with strictures at the liver hilum, diagnosed by computed tomography and/or ERCP prospectively and consecutively underwent EUS-FNA with longitudinal echoendoscope and 22 gauge needles. Results: In 9 patients adequate material was achieved. Cytology revealed chloangiocarcinoma in 7 patients and hepatocellular carcinoma in one. 8 out of ten patients underwent surgery, in the other two lymph node and liver metastases were detected during pre-surgery examinations. In these EUS-FNA cytology revealed adenocarcinoma. One benign inflammatory lesion on cytology proved to be false negative in frozen section. No complication occurred. Accuracy, sensitivity, and positive predictive value were 89%, 89% and 100%, respectively. Conclusion: Primary cholangiocarcinoma of the hilum can be difficult to discern from other malignancies or benign lesions. These results suggest that EUS-FNA is a new less invasive approach for tissue diagnosis of Klatskin tumors, which for the first time proved to be technically feasible without significant risks.